Stroke patients are invited to print off this form

The staff of the Stroke Service need your feedback; it can help them to achieve continuous improvement.Relatives are encouraged to fill in the form on behalf of the patient if this is easier.We also welcome relatives’ own response to the questions.

Name (patient) ___________
Date of birth ______

Address ___________________________
___________________________________

If you are filling in this form as a family carer or friend of the patient please tell us your name and address or phone number, if different from patient’s:-
______________________________
______________________________

1. When did you have your stroke? (month and year) ____________________

Give date of most recent stroke, if you have had more than one.
______________________________

2. Were you admitted to hospital? Yes
No
IF YES
Which Hospital/s? _________________________________________________
Which ward/s? _____________
How long were you there? __________________
Have you any comments about the care you received while in hospital?































3. Did you go home after this or were you transferred elsewhere?

Home
Transferred for rehabilitation to _________________________________________
Other
Please specify _________________________________________

4. We would like to know what you thought about the treatment and care you had after your stroke. What things were good about it?

Were there things you were less happy about?











5. Have you any suggestions for improving the care and treatment of stroke patients?







6. How did your family cope?

Did you and your family have enough information about stroke – causes, treatment, recovery etc?
YES
NO
IF YES Where did you get information from?

IF NO What further information would have been helpful?

7. Is there anything else you would like to add?











Please let us know if you would like information about stroke clubs in your area

IMPORTANT NOTE
The purpose of this form is to enable us to have your concerns, if any, investigated, and your comments, good or bad, passed on to the appropriate people. This means we may need to share the information you have given us with those who work in the stroke service. If, however, you don’t want your name divulged please tell us.
We can still take up your comments in a general way, even if you would prefer us not to reveal your name.

your help is much appreciated – many thanks